The present invention relates to a device and method for delivering a therapeutic substance to the myocardium of a human heart.
Tissue becomes ischemic when it is deprived of adequate blood flow. Ischemia causes pain in the area of the affected tissue and, in the case of muscle tissue, can interrupt muscular function. Left untreated, ischemic tissue can become infarcted and permanently non-functioning. Ischemia can be caused by a blockage in the vascular system that prohibits oxygenated blood from reaching the affected tissue area. However, ischemic tissue can be revived to function normally despite the deprivation of oxygenated blood because ischemic tissue can remain in a hibernating state, preserving its viability for some time. Restoring blood flow to the ischemic region serves to revive the ischemic tissue.
Although ischemia can occur in various regions of the body, often tissue of the heart, the myocardium, is affected by ischemia due to coronary artery disease, occlusion of the coronary arteries, which otherwise provide blood to the myocardium. Muscle tissue affected by ischemia can cause pain and lead to infarction of the tissue. Ischemia can be treated, if a tissue has remained viable despite the deprivation of oxygenated blood, by restoring blood flow to the affected tissue.
Treatment of myocardial ischemia has been addressed by several techniques designed to restore blood supply to the affected region. Coronary artery bypass grafting (CABG) involves grafting a venous segment between the aorta and the coronary artery to bypass the occluded portion of the artery. Once blood flow is redirected to the portion of the coronary artery beyond the occlusion, the supply of oxygenated blood is restored to the area of ischemic tissue.
Early researchers, more than thirty years ago, reported promising results for revascularizing the myocardium by piercing the muscle to create multiple channels for blood flow. Sen, P. K. et al., xe2x80x9cTransmyocardial Acupuncturexe2x80x94A New Approach to Myocardial Revascularizationxe2x80x9d, Journal of Thoracic and Cardiovascular Surgery, Vol. 50, No. 2, August 1965, pp. 181-189. Although others have reported varying degrees of success with various methods of piercing the myocardium to restore blood flow to the muscle, many have faced common problems such as closure of the created channels. Various techniques of perforating the muscle tissue to avoid closure have been reported by researchers. These techniques include piercing with a solid sharp tip wire, hypodermic tube and physically stretching the channel after its formation. Reportedly, many of these methods still produced trauma and tearing of the tissue that ultimately led to closure of the channel.
An alternative method of creating channels that potentially avoids the problem of closure involves the use of laser technology. Researchers have reported success in maintaining patent channels in the myocardium by forming the channels with the heat energy of a laser. Mirhoseini, M. et al., xe2x80x9cRevascularization of the Heart by Laserxe2x80x9d, Journal of Microsurgery, Vol. 2, No. 4, June 1981, pp. 253-260. The laser was said to form channels in the tissue that were clean and made without tearing and trauma, suggesting that scarring does not occur and the channels are less likely to experience the closure that results from healing. U.S. Pat. No. 5,769,843 (Abela et al.) discloses creating laser-made TMR channels utilizing a catheter based system. Abela also discloses a magnetic navigation system to guide the catheter to the desired position within the heart. Aita U.S. Pat. Nos. 5,380,316 and 5,389,096 disclose another approach to a catheter based system for TMR.
Although there has been some published recognition of the desirability of performing transmyocardial revascularization (TMR) in a non-laser catheterization procedure, there does not appear to be evidence that such procedures have been put into practice. For example, U.S. Pat. No. 5,429,144 Wilk discloses inserting an expandable implant within a preformed channel created within the myocardium for the purposes of creating blood flow into the tissue from the left ventricle.
Performing TMR by placing stents in the myocardium is also disclosed in U.S. Pat. No. 5,810,836 (Hussein et al.). The Hussein patent discloses several stent embodiments that are delivered through the epicardium of the heart, into the myocardium and positioned to be open to the left ventricle. The stents are intended to maintain an open channel in the myocardium through which blood enters from the ventricle and perfuses into the myocardium.
Angiogenesis, the growth of new blood vessels in tissue, has been the subject of increased study in recent years. Such blood vessel growth provides new supplies of oxygenated blood to a region of tissue that has the potential to remedy a variety of tissue and muscular ailments, particularly ischemia. Primarily, the study has focused on perfecting angiogenic factors such as human growth factors produced from genetic engineering techniques. It has been reported that injection of such a growth factor into myocardial tissue initiates angiogenesis at that site, which is exhibited by a new dense capillary network within the tissue. Schumacher et al., xe2x80x9cInduction of Neo-Angiogenesis in Ischemic Myocardium by Human Growth Factorsxe2x80x9d, Circulation, 1998; 97:645-650. The authors noted that such treatment could be an approach to management of diffused coronary heart disease after alternative methods of administration have been developed.
The present invention provides a transthoracic drug delivery device that is specially configured to be precisely located in the myocardium for accurate placement of a therapeutic substance such as a drug. The device comprises a syringe having a delivery tube that is capable of penetrating the myocardium via the epicardium to access the left ventricle. Access to the heart is gained through the thorax. A pressure monitor associated with the device indicates the position of the distal tip of the delivery tube. It is noted that, throughout the discussion of the invention in the specification, xe2x80x9cdistalxe2x80x9d is meant to indicate the direction along the access path of the device leading internal to the patient and xe2x80x9cproximalxe2x80x9d indicates the direction along the access path leading external to the patient. Pressure may be monitored through the delivery tube or through a separate pressure tube associated with the delivery tube. Specifically, the amount of pressure measured through the tube of the device informs the physician whether the distal port of the tube has penetrated the myocardium completely to reach the left ventricle. In the case of separate delivery and pressure tubes, the distance between the pressure tube opening and drug delivery tube opening is known, so the user can determine whether the drug delivery tube opening is still within the myocardium, and, therefore, appropriately placed to inject a drug into the myocardium. Multiple drug delivery tubes may be associated with the device to perfuse the drug more quickly through multiple ports into the myocardium. It is noted that throughout the specification xe2x80x9cdrugxe2x80x9d includes all varieties of therapeutic substances that may be beneficial to the body, including pharmaceutical agents, genetically engineered substances or natural substances.
In another embodiment, a pressure sensing hypodermic tube, as in the first embodiment, is used to transthoracically access the heart and penetrate the left ventricle. However, the second embodiment is comprised of a single pressure sensing tube. The distal portion of the pressure tube is flexible and made controllable or steerable by mechanisms well known in the art of catheter manufacture such as a pull wire bonded to the distal end of the tube and extending proximally for manipulation outside the patient. After penetrating the left ventricle, the single pressure tube may be bent into a xe2x80x9cJxe2x80x9d configuration and the shaft withdrawn proximally to cause the curved tip of the J portion to penetrate the myocardium again, through the endocardial surface while moving in a proximal direction, similar to a fish hook. Entrance of the distal port of the pressure tube into the tissue results in a drop of measured pressure, indicating to the user that the distal tip of the pressure tube is within tissue, and, thus, appropriately placed to inject the drug or therapeutic substance being carried by the device.
After delivery of the therapeutic substance to a first location, the distal tip of the pressure tube may be backed out of the tissue by distal movement of the device into the ventricle and another location accessed. The steerable distal tip of the device permits the distal tip to be deflected through various angles relative to the longitudinal axis of the tube. Combining this range of movement with the rotational capability inherent in the device provides a locus of points about the penetration point into the ventricle where the distal tip of the needle can be placed into the myocardium to deliver therapeutic substances.
It is an object of the present invention to provide a drug delivery device that can access the myocardium and left ventricle of the heart transthoracically and accurately indicate the position of the distal tip of the device within the heart.
It is another object of the invention to provide a drug delivery device that is capable of delivering a therapeutic substance to the myocardium of the heart accurately and easily.
It is yet another object of the invention to provide a drug delivery device that is capable of delivering a therapeutic substance to the myocardium of the heart quickly via a plurality of delivery conduits.
It is yet another object of the invention to provide a drug delivery device that is capable of reaching a plurality of delivery locations in the myocardium with a single access to the heart.
It is yet another object of the invention to provide a drug delivery device for placement within the heart that is associated with a pressure sensor having adequate sensitivity to discern whether the pressure sensor port is within the myocardium or within the left ventricle.
It is yet another object of the invention to provide a delivery device that is configured to have a deflectable tip so that the reverse side of tissue having been accessed by the device can also be penetrated by the sharp tip of the device as the device is moved back along its access path.